Development of a conceptual framework to understand the stakeholder’s perspectives on needs and readiness of rural tele-practice for childhood communication disorders

Background Tele-practice promotes universal and equitable access to quality health services and emerged as an alternative to overcome physical barriers to intervention access in the 90s. There has been a steady increase in adoption since then, and during the COVID-19 pandemic, there was a surge in online modes of healthcare service delivery. Yet, tele-practice adoption and utilization in rural and remote areas are not spontaneous. Therefore, as a first step, prior to the implementation of a comprehensive tele-practice model, a baseline situational analysis was undertaken to assess the needs and readiness of parents of children with disabilities and different cadres of health care providers towards accepting tele-practice services in their settings. This paper describes the process of development of the conceptual framework that guided the baseline needs and readiness assessment (situational analysis). Methods The Bowen's feasibility framework served as the primary framework to evaluate the feasibility outcomes of the implementation. Therefore, this framework also guided the baseline situational analysis. For specificity of the framework to tele-practice, several telemedicine planning frameworks relevant for low- and middle-income countries were reviewed to identify and map suitable constructs and attributes to the Bowen’s constructs. A description of the framework selection process and a review of each of the selected telemedicine frameworks are provided. Results The constructs and attributes from this conceptual framework were used to develop the guides for focus group discussions (FGDs) and semi-structured interviews (SSIs). The guides were prepared separately for each stakeholder group. Conclusions The developed framework facilitated the assessment of needs and readiness suited to the context and among various stakeholders involved in the proposed implementation of the comprehensive model of tele-practice for childhood communication disorders in rural communities.

specificity of the framework to tele-practice, several telemedicine planning frameworks relevant for low-and middle-income countries were reviewed to identify and map suitable constructs and attributes to the Bowen's constructs.A description of the framework selection process and a review of each of the selected telemedicine frameworks are provided.

Results
The constructs and attributes from this conceptual framework were used to develop the guides for focus group discussions (FGDs) and semi-structured interviews (SSIs).The guides were prepared separately for each stakeholder group.

Conclusions
The developed framework facilitated the assessment of needs and readiness suited to the context and among various stakeholders involved in the proposed implementation of the comprehensive model of tele-practice for childhood communication disorders in rural communities.

Introduction
Tele-practice promotes universal and equitable access to quality health services.Digital health can contribute to the sustainability and efficiency of health systems, allowing them to provide affordable, equitable, and high-quality care (World Health Organization, 2021).Tele-practice emerged in health care sectors to overcome physical barriers to intervention access in the 90s (Hodge et al., 2019;Law et al., 2021).There has been a steady increase in adoption since then, and during the COVID-19 pandemic there was a surge in online modes of healthcare service delivery (Lamash et al., 2023;Law et al., 2021;Leung et al., 2023;Shahouzaie & Gholamiyan Arefi, 2022).Therefore, tele-practice is now considered a more mainstream model of health care provision.
Tele-practice has been used to address service delivery gaps in childhood disability (Akulwar-Tajane & Bhatt, 2021;Camden et al., 2020;Ogourtsova et al., 2023) and more specifically to support rehabilitation of speech, language and hearing disorders (Dimer et al., 2020;Ebrahimi et al., 2024;Eslami Jahromi et al., 2022).However, most of the tele-practice in audiology and speech language pathology seems to be implemented through funded research (Ramkumar et al., 2023;Shankar et al., 2022) in high-income countries (HICs) and predominantly in urban settings.But the need is maximum for those living in rural communities who rely largely on public health services (Roy, 2023;Tulimiero et al., 2021).This is truer for low-and middle-income countries (LMICs).Yet, tele-practice adoption and utilization in rural and remote areas has not been easy owing to reluctance of clinicians in rural areas and rural patients to adopt tele-practice (Banbury et al., 2023).
The successful implementation of tele-practice services in the public and/or private sectors in rural areas requires careful planning through assessment of the needs of a population and their readiness for availing these services.This is best done using a well thought through conceptual framework that "defines the current state of knowledge (based on literature review), identifies gaps in the understanding of a phenomenon or problem, and provides the methodological basis for the research work" (Varpio et al., 2020).
A funded project was initiated to assess the feasibility of implementing a comprehensive tele-practice model for the identification and rehabilitation of children with hearing and speech-language disorders in rural communities in Southern India.Therefore, as a first step, prior to implementation, a baseline situational analysis was undertaken to assess the needs and readiness of parents of children with disabilities and different cadres of health care providers towards accepting tele-practice services in their settings.The Bowen's feasibility framework (Bowen et al., 2009) was selected as the primary framework to evaluate the feasibility outcomes of the implementation.Therefore, this framework also guided the baseline situational analysis.However, for specificity of the framework to tele-practice, several telemedicine planning frameworks were reviewed to identify and map suitable constructs and attributes to the Bowen's constructs.This paper describes this process of development and the finalized conceptual framework that guided the baseline needs and readiness assessment (situational analysis).

Methods
Ethical approval was obtained from Institutional Ethics Committee of Sri Ramachandra Institute of Higher Education and Research (DU) on 25.11.2019(IEC-NI/19/NOV/71/90).
The COnsolidated Criteria for REporting Qualitative Research (COREQ) Checklist (Tong et al., 2007) was used to develop and report the domains of study team and reflexivity, and study design (checklist available as Extended data (Ramkumar, 2024)).The Bowen's feasibility framework and several telemedicine frameworks applicable for LMICs settings were reviewed.A description of the framework selection process and a review of each of the selected telemedicine frameworks are provided below.

Review of literature and selection of telemedicine framework
Using search engines and keywords (telemedicine planning or tele-practice, planning, readiness assessment, needs, and framework), a literature search was conducted by the first and second authors (females, audiologist and speech language pathologists).Both of these authors are already trained in qualitative research methods.The literature search led to 22 articles on telemedicine planning.Three experts reviewed these 22 articles and excluded those that did not pertain to LMICs or irrelevant to rural context.Any discrepancies were resolved based on consensus.This resulted in a final set of seven articles that were considered for the mapping process.The summary of the selected telemedicine frameworks is provided in Table 1.
Three experts with experience in tele-practice reviewed the constructs of the finalized seven articles on telemedicine planning.The identified concerns were subsequently addressed, and the conceptual framework was finalised.

Mapping the attributes of telemedicine framework to the Bowen's feasibility framework
The primary framework to study feasibility outcomes was the Bowen's feasibility framework (Bowen et al., 2009) which includes the constructs of acceptability, demand, implementation, practicability, adaptation, integration, expansion, and limited efficacy.While the construct of demand was chosen to understand the demands or needs of tele-practice, the constructs of acceptability, integration, and practicality were chosen to understand the readiness of tele-practice.The study team visited the research locations to gain knowledge about the current health services, systems, infrastructure available and various cadres of health care providers in these communities.
The constructs were reviewed and included in an iterative manner guided and influenced by the understanding of the research locations.Using the constructs identified following our telemedicine frameworks literature review, three experts mapped these to the constructs of Bowens feasibility framework to explore the needs and readiness for telepractice in rural areas for childhood communication disorders (Table 2).All these attributes were selected based on the study's research objectives.

Results
This conceptual framework was used to obtain the perspectives of various stakeholders involved in the study to assess their needs and readiness towards accepting tele-practice services in their settings.The stakeholders were health care providers (HCPs) and parents in two rural districts in the state Parents of children with disabilities were also included.
The conceptual framework were used to develop the guides for focus group discussions (FGDs) and semi structured interviews (SSIs) (available as Extended data (Ramkumar, 2024)).
The guides were prepared separately for each stakeholder group.We followed the five phases for the development of the SSI guide that were provided by Kallio et al. (2016): identifying the prerequisites for using semi-structured interviews; retrieving and applying prior knowledge; formulating the preliminary semi-structured interview guide; pilot testing the guide; and presenting the complete guide.We followed the same five phases for the development of the FGD guide as well.
The guides were further enhanced and improved by integrating the insights obtained from each focus group discussion and interview, thereby enabling a deeper understanding.Prior to data collection, two specialists with expertise in qualitative research and tele-practice conducted a further review of the guides to ensure that they were concise, easy to comprehend, and pertinent to the research objectives.The main questions were followed by probe questions to ensure that the perspectives obtained were pertinent to the research question.Two experts in the field validated the guides, and based on their suggestions, modifications were made to the guides.The guide was then tailored to the needs of each stakeholder group.Prior to the data collection, a pilot test was conducted with the guide.
Interviews with a semi-structured method were selected to collect individual responses to the research question.If any stakeholder group had less than five members, an SSIs was conducted with the participant's consent.The guides were used to understand perceptions of the health care providers on their training needs, infrastructure availability, time management between administrative and clinical work and challenges in providing consistent diagnostic and rehabilitation services will be explored.Their perceptions of barriers and facilitators to tele-practice implementation and their readiness for adopting it were explored.More specifically, SSI guides were developed for the DDAW officers, multi-purpose rehabilitation therapist ASLPs, special educators and EIC incharges, FGDs were carried out with SSA Special educators, anganwadi workers and VHNs as well as with parents of children with disabilities.A separate guide was developed to understand caregiver perceptions regarding the availability and accessibility of diagnostic and rehabilitation facilities, barriers and challenges encountered in seeking care, and satisfaction with quality of care, including cost-related issues and their readiness to accept tele-practice.

Conclusion
A context and content specific needs and readiness framework was developed to guide the implementation of tele-practice for childhood communication disorders in rural communities.

Limitations
The conceptual framework was only implemented within a limited geographic area, specifically confined to a few districts in the southern region.It will be worthwhile to apply this framework to other regions in India and other low-and middle-income countries.
This project contains the following extended data: -COREQ checklist -Guides for FGD and SSI developed using the conceptual framework for health care providers -Guides for FGD and SSI developed using the conceptual framework for parents Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0).

Open Peer Review
Current Peer Review Status:

Kate Bridgman
La Trobe University, Melbourne, Victoria, Australia Thank you for the opportunity to review this article titled 'Development of a conceptual framework to understand the stakeholder's perspectives on needs and readiness or rural tele-practice for childhood communication disorders'.The authors are to be commended for the detail of this study -first conducting a review to select suitable frameworks to then inform focus group interviews.
The following comments are offered to refine specific details to increase clarity for a firsttime reader: Terminology -the population is referred to differently throughout the manuscript, for e.g.childhood communication disorders (titled), children with disabilities (abstract), children with hearing and speech-language disorders (plain English summary and introduction).For clarity, it would be best to use title 'childhood communication disorders' throughout.

1.
History of telepractice -the authors reports that telepractice emerged in the 90s, however use and development of telepractice/telehealth predates the 1990s (for e.g.The Evolution of Telehealth: Where Have We Been and Where Are We Going?-The Role of Telehealth in an Evolving Health Care Environment -NCBI Bookshelf (nih.gov)) 2.
References -introduction paragraph 3 -a reference would strengthen the statement 'The successful implementation of tele-practice services in the public and/or private sectors in rural areas requires careful planning through assessment of the needs of a population and their readiness for availing these services.'

3.
Details of search -are the exact search terms listed?Typically the terms including truncations, wildcards and Boolean operators are listed, as are the exact databases that are used.Are the conclusions about the method and its performance adequately supported by the findings presented in the article?Yes

Constructs -
Competing Interests: No competing interests were disclosed.
I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.
conceptual framework for a needs assessment for a new tele-practice to provide speech and language therapy for children with communication impairments in rural South India.It draws on a number of previously produced frameworks to develop one suitable for this purpose.
It is generally well written, clear, succinct and easy to follow.It is a systematic description of the process.
There is very little need for change, but I have listed a few places where the expression could be clearer or more grammatical, see below: In results section: End of 1st para-'Parents of children with disabilities were also included' This makes them sound like an afterthought, whereas surely they are probably the most important group of respondents?Adjust the wording maybe?.
○ 2nd para-The conceptual framework was used.
○ 'Interviews with a semi-structured method' -adjust to > 'Interviews using a semistructured'.

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'The guides were used to understand perceptions of the health care providers on their training needs, infrastructure availability, time management between administrative and clinical work and challenges in providing consistent diagnostic and rehabilitation services will be explored'.Need to adjust grammar of these sentences.

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'their readiness for adopting it were explored' adjust to > readiness to adopt it.

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Last few sentences of last paragraph in Results are slightly confusingly worded.You've already said that you specifically designed the topic guide for each group, including parents and then you mention caregivers.Need to adjust this paragraph for consistency.However, giving the example of the kinds of things you planned to ask parents/caregivers is good though, so retain this in your rephrase.Reviewer Expertise: Speech and language therapist and anthropologist, with research interests in disability in the Global South.Particularly developing and using qualitative, participatory , disability inclusive projects, asking children and families about their experiences and perspectives.
Working with disabled children and adults as peer researchers and active participants.Geographical foci in India, Sri Lanka, Bangladesh and also in East Africa.
I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

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Additionally -I would have been interested in some mention of the possibility of asking children themselves what they would think about a tele therapy approach.You clearly weren't thinking of doing that but the possibility deserves a mention!Is the rationale for developing the new method (or application) clearly explained?YesIs the description of the method technically sound?YesAre sufficient details provided to allow replication of the method development and its use by others?YesIf any results are presented, are all the source data underlying the results available to ensure full reproducibility?Partly Are the conclusions about the method and its performance adequately supported by the findings presented in the article?Yes Competing Interests: No competing interests were disclosed.

Table 2 . A conceptual framework to study the needs and readiness for tele-practice in rural areas for childhood communication disorders.
This is an open access peer review report distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Is the rationale for developing the new method (or application) clearly explained? Yes Is the description of the method technically sound? Yes Are sufficient details provided to allow replication of the method development and its use by others? Partly If any results are presented, are all the source data underlying the results available to ensure full reproducibility? Partly
Table 1 is well presented and represents a summary of each framework, an additional column explaining the construct of definition may help readers with new 5. concepts -for e.g.what is meant by 'technology readiness' and 'E-learning readiness', and how might these differ?What is meant by, or an example of 'effort expectance'?.This could also be included for Table 2 -for e.g.what is meant by 'policy will'?